Page 48 - GTM-3-2

Global Translational Medicine Prognostic indicators and management of SAP

Agents targeting pancreatic secretion, including trypsin (odds ratio [OR] = 2.893; confidence interval [CI] 95%
inhibitor aprotinin, platelet activator factor (PAF) inhibitor, = 1.371 – 6.105; P = 0.005 and, respectively OR: 0.346;
protease inhibitor (gabexate mesylate), and octreotide, have CI 95% = 0.156 – 0.765; P = 0.009), without biliary stent
shown no benefit, according to a recent meta-analysis. placement. In addition, the data analysis provided new
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However, lexipafant (a PAF inhibitor) is thought to research evidence, demonstrating that higher values of
reduce the disintegration of the intestinal mucosa, thereby CRPR-CRP after ERCP/CRP on admission: OR = 4.337;
suppressing systemic inflammatory response syndrome. CI 95% = 1.945 – 9.668; P < 0. 001; total bilirubin inverted
Two randomized trials have demonstrated its involvement ratio: OR = 4.004; CI 95% = 1.664 – 9.634; P = 0.002; and
in reducing the rate of sepsis and multivisceral failure, but neutrophil lymphocyte ratio: (OR = 3.281; CI 95% = 1.490
it has no effect on mortality. 62,63 – 7.221; P = 0.003) predicted the occurrence of PEP. 70

3.2.2. Radio-guided and endoscopic therapeutic 3.2.3. Surgery
procedures Surgery should be postponed until at least the 30 day,
th
Peritoneal dialysis by puncture-washing has shown a timeline adopted by the majority of international
its efficacy on cardio-respiratory function but without pancreatology societies. This waiting period is associated
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any effect on reducing mortality. The radiation-guided with lower morbidity and mortality. 71-75 This attitude
puncture of infected collections or pseudocysts using allows a patient to be operated on after stabilization of the
large-bore drains (24 Charrière) gave very good results in systemic inflammatory reaction and after demarcation of
a French study (100% survival in pancreatic abscesses), the necrotic lesions from the healthy parenchyma, which is
provided that irrigation was associated. The disadvantage a valuable aid for the surgeon. The current best indicator of
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of this approach is the appearance of a pancreatic fistula. the time for surgery is the increase in the APACHE II score
Drainage has, above all, a temporizing role by avoiding during the intensive care period. In general, the indication
recourse to surgery in the acute phase because delayed for surgery is in three situations (Table 7 and Figure 1):
surgical treatment of well-limited lesions allows en bloc (i) In a rare group of patients, early intervention is
necrosectomy to be performed, removing all the necrotic necessary when their state of health deteriorates
debris and thus avoiding repeat operations. despite aggressive care; this may be due to massive
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When a hemorrhage or an aneurysm is detected, hemorrhage or perforation. Early surgery is also
an embolization can be used to stop it. Puncture under indicated in cases of compartment syndrome, which
echo-endoscopy is particularly recommended when the complicates up to 80% of PAS. 75-77 When the IAP
pseudocyst is retro-gastric and after 4 weeks to achieve exceeds 25 mmHg, decompression by laparotomy is
a certain “maturity” of the collection. The placement indicated, which improves hemodynamic status as
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of a stent allows for internal drainage of the collection. well as respiratory and renal function.
The endoscopic sphincterotomy (ES) is very useful in (ii) Infected pancreatic necrosis;
severe obstructive biliary pancreatitis in the acute phase (iii) Certain complications of sterile necrosis may lead to
(first 72 h) with a grade 1A recommendation. 45,51 This surgery. Firstly, in the event of sterile necrosis exceeding
procedure may improve the prognosis, but the latter 50% of the pancreatic area and requiring assisted
remains dependent, above all, on the extent and infection ventilation or hemodialysis, surgery is indicated. It
of the necrosis. 65-68 Candidates for ES should be selected may also be persistent AP, or AP due to refeeding.
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by echo-endoscopy or cholangio-MRI in order to limit Ductal interruption syndrome is often associated with
unnecessary ones without choledocholithic or oddial these conditions and is thought to result from necrotic
obstruction. Performing an endoscopic retrograde rupture of the pancreatic duct, leading to retention of
cholangiopancreatography (ERCP) for biliary pancreatitis pancreatic juice in the distal part of the gland. This
where the obstruction has not been confirmed would anatomical condition responds well to a pancreatico-
unnecessarily increase the risk of infection, especially jejunal anastomosis on a Y loop; otherwise, there is a
fungal infection. Furthermore, ES carried inherent risks, risk of transitioning to chronicity. Generally speaking,
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with a mortality rate of 2% and a morbidity rate of 8%. In however, in cases of sterile necrosis, the results
the study by Boicean et al. involving 134 patients who obtained with a conservative therapeutic strategy
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performed ERCP to extract choledochal lithiasis (n = 48 are comparable to those obtained with a surgical
with post-ERCP pancreatitis [PEP] and n = 86 without approach; 30 to 60% of SAP with sterile necrosis are
PEP), a higher risk of PEP was observed in female subjects cured without recourse to surgery. 54,81 Furthermore,
and lower risk in patients who underwent main bile duct mortality in cases where sterile necrosis is surgically
clearance with the Dormia probe and dilatation balloon debrided is 12% to 21%, and when it is treated non-

Volume 3 Issue 2 (2024) 7 doi: 10.36922/gtm.2480